Provider Demographics
NPI:1043633324
Name:MICELI, BENJAMIN (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MICELI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 S LEMAY AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3960
Mailing Address - Country:US
Mailing Address - Phone:970-495-7421
Mailing Address - Fax:970-495-7424
Practice Address - Street 1:1107 S LEMAY AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3960
Practice Address - Country:US
Practice Address - Phone:970-495-7421
Practice Address - Fax:970-495-7424
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14330318Medicaid
CO340185YLB8Medicare PIN